Provider Demographics
NPI:1780101469
Name:LY, PHUNG KIM
Entity type:Individual
Prefix:
First Name:PHUNG
Middle Name:KIM
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 S MARENGO AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1950
Mailing Address - Country:US
Mailing Address - Phone:571-232-9363
Mailing Address - Fax:
Practice Address - Street 1:703 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3232
Practice Address - Country:US
Practice Address - Phone:626-289-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist